Penile pain- “What`s wrong, doc?”

Penile pain“What’s wrong, doc?”
Lincoln Tan
Registrar
“The Good”
Penile pain associated with symptoms or signs consistent
with common causes e.g STDs, UTIs
“The Bad”
Chronic penile pain without other features pointing to an
obvious cause e.g pelvic pain syndromes
Often difficult to treat
“The Ugly”
Penile emergencies where diagnosis may be obvious but
urgent management if required
Approach
History
Acute vs chronic
Dysuria vs pain independent of voiding
During erection? During ejaculation?
Unprotected sex/ CSW
Previous surgery/ urethral instrumentation
Associated symptoms
Urethral discharge
Scrotal or perineal pain/ numbness
Previous loin/groin pain/haematuria
Approach
Physical examination
Penile mass
Penile plaque
Penile sores/ulcerations/ inflammation
Urethral meatus
Inguinal nodes
Abdominal, scrotal, prostate
examination
Investigations
UFEME/urine culture
Urethral swabs
Kiv flexible cystoscopy
The ugly!
Penile emergencies
Penile fracture
During sexual intercourse
“Crack”
“Egg plant” deformity
Surgical management
Paraphimosis
Inability to reduce the foreskin
Most common after catheterisation
Adequate analgesia
Consider penile block
Lubrication
Manual reduction
Dorsal slit
Elective circumcision
Priapism
Erection > 4 hours not a/w sexual stimulation
Causes
ED therapy
Antipsychotics, illicit drugs, antidepressants,
anticoagulants
Sickle cell anemia, hematological malignancies
Perineal/pelvic trauma
Analgesia
Refer to ED for management
Penile cancer
Often clinically obvious
Beware “chronic balanitis”; lesion under
phimotic penis
Refer to dermatology for biopsy of
suspicious lesions that are chronic and
do not respond to treatment
Refer to Urology for definitive treatment
The good
Infections
UTIs
STDs
Balanitis +/- posthitis
Male UTI
Less common in men <50 compared to females
Dysuria, frequency, urgency
Look for alarm symptoms – haematuria
Urine dipstick/urine culture
Antibiotics x minimal 1 week
If a/w fever, commonly involve prostate 2/52 antibiotics
and refer to urologist for review
STDs
Usually associated with
urethritis (dysuria) +/- urethral
discharge
Gonorrhea
Chlamydia
Syphilis
STDs
Urethral swabs for GC and Chlamydia
Notify, refer to DSC
Exclude HIV
Contact tracing + mx of sex partners
Gonorrhea
I/M Ceftriaxone 250mg single dose + Rx for Chlamydia
Chlamydia
Azithromycin 1g single dose OR doxycycline 100mg bd x
1/52
Balanoposthitis
Usu in uncircumcised men
DM risk factor
Fungal or bacterial
Antibiotics/antifungals
Hygiene advice
Circumcision in recurrent cases
Beware of persistent balanitis may be penile CIS in disguise!
Painful penile dermatoses
Chemical dermatitis
Candida balanitis
Fixed drug eruption
pruritic or burning,
appears within days to weeks of
initiating culprit drug and resolves after
withdrawal of the medication
Often recur at the same sites within
hours of drug rechallenge and heal
with residual hyperpigmentation
most common causative agents are
antibiotics
Drug rechallenge
Patch testing and intradermal skin
testing are other options
Pain during intercourse
Tight foreskin
Circumcision
Short frenulum
Frenuloplasty or circumcision
Peyronies disease
Curvature only apparent on
erection
Ask specifically for it
Refer to urologist
Acute painful phase
Pain during erection/ flaccid/
palpation
Pentoxifylline
Chronic painless phase
Surgical correction
Urethritis
Urethral pathology
Strictures
Stone
Urethral pain a/w difficulty voiding or retention
Stone may be palpable along shaft of penis
Referral to urologist for cystoscopy and removal
Urethral pain syndrome
Dysuria (with or without frequency, nocturia,
urgency and urge incontinence) in the absence
of evidence of urinary infection
Exclude UTI/STDs
Flexible urethrocystoscopy
No consensus on treatment
Trial of alpha-blockers; NSAIDS;
accupuncture
Pain team referral if above fails
Referred pain
Keep in mind, especially in
the absence of physical
findings
Stone in the distal ureter or
bladder
Neuropathies
Pudendal nerve compressions
Preceded by genital numbness
May be a/w sexual dysfunction such as
ED, altered sensation of
ejaculation/orgasm
Compression in Alcock canal or just
outside pelvis during cycling
Ilioinguinal nerve
Pain, parasthesia/numbness over base of
penis and scrotum and upper medial thigh
Injury after lower abdominal incisions, e.g
appendectomy, inguinal herniorrhaphy,
inguinal lymph node dissection
Management of Neuropathies
If related to cycling
changing the riding style and schedules as well as modifying
the design of the saddle and its positioning
Gabapentin/ amitriptylline
Trial of local anaesthesia
Physical therapy
Surgical excision
The bad
Painful ejaculation
Prostatitis
Urethral pathology
Ejaculatory duct obstruction
May be a/w decreased semen
volume/subfertility
Psychogenic
Pain on orgasm usu a/w spinal
or pelvic injury
Prostate pain syndrome
Previously known as prostatitis
Penile pain (usu after ejaculation)
May be a/w perineal/scrotal/rectal pain
Prostate may or may not be tender
Urine dipstick may be normal
Raised white cells or positive culture from expressed
prostatic secretions or post prostatic massage urine
Diagnosis of bacterial prostatitis
4 glass test
Semen culture
Bacterial prostatitis
Acute bacterial prostatitis
Acutely ill, febrile, tender prostate
Admission for IV antibiotics, rule out abscess
At least 2/52 of antibiotics to prevent
progression to chronic prostatitis
Chronic bacterial prostatitis
Cipro/bactrim x 2/52 – if symptoms relieved,
complete 6 weeks
NSAIDS, alpha-blockers, Sitz baths
Chronic pelvic pain syndrome
(CPPS)
Culture negative, WBC in semen/EPS/VB3
Difficult to treat
Counsel patient symptoms may be
prolonged, will wax and wane, treatment
largely empirical
Single trial of empiric antibiotics x 4-6/52
Analgesia – NSAIDS, opiates
5α-reductase inhibitors/phytotherapy
Pelvic relaxation exercises;
accupuncture
Pelvic floor dysfunction
Overactive pelvic floor
Muscular ache
Compression of nerves/vessels
to penis
Myofascial trigger points
Physiotherapy
Amitriptylline/gabapentin
Injection with LA
Conclusion
Common causes of penile pain can be diagnosed with
careful history and physical exam
Exclude UTI/STDs/local skin conditions
The “bad” and “ugly” of penile pain should be referred to
urologists